A case of posterior reversible encephalopathy syndrome (PRES) on the third day after total laparoscopic hysterectomy (TLH)

A 43-year old woman presented with severe anemia due to myomas and received oral iron supplementation. Three months later, after the recovery of severe anemia from Hb 4.2 g/dl to13.5 g/dl, was confirmed(Hb 13.5g/dl), we performed a total laparoscopic hysterectomy. Three days after operation, the patient had altered mental functioning and seizure. The FLAIR MR imaging revealed high signal intensity in the bilateral occipital lobes, and the patient was diagnosed as PRES. We immediately injected Nicardipine intravenously to lower the systolic blood pressure below 120mmHg. No seizures occurred after the administration of Nicardipine. Four days later, the high signal seen in FLAIR MR imaging significantly diminished. A follow up MR imaging in three months revealed the disappearance of the lesion. PRES is typically characterized by symptoms of headache, altered mental functioning, seizure, and visual impairment. FLAIR MR imaging is especially beneficial in diagnosing PRES. Patients with PRES often show high signal intensity in the occipital, temporal and parietal lobes. There are many known factors associated with PRES such as hypertension, immunosuppressive drug therapy for neoplasm or organ transplantation and more. In the field of obstetrics and gynecology, eclampsia, hypertensive disorders of pregnancy and the treatment of severe anemia are associated with PRES. Notably, the treatment of severe anemia due to myomas could induce PRES at any point of time. There have been reports of PRES seen a few days after transfusion, a few months after oral iron supplementation, and even a year after treatment. Although PRES is a rare disease, it is essential to keep PRES in mind when patients suddenly present with neurological symptoms during and after the treatment of severe anemia due to myomas, regardless of the route of administration.